HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 FARNUM STREET 4/28/2021 : Commonwealth of Massachusetts
City/Town of APR 03 2021
System Pumping Record
r .0 Cl HEtp LT;-j
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left J Right rear of house, Left/ gh�Mk
ous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building,
Address <--Lq 0 v\U V,_ -s`- oc-<-
Cilyfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitjATown Stafe r �� LCode
Telephone Number
6. Pumping Record Dr
1. Date of Pumping Date2 Quantity Pumped:
GaAons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:k1"_ �✓�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
L S Lowell Waste Water
Signiture qt Haulmu Date
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